Industrial Relations Commission of New South Wales s1

INDUSTRIAL RELATIONS COMMISSION OF NEW SOUTH WALES

APPLICATION FOR WAIVER OR REDUCTION OF FILING FEE FOR APPLICATIONS

Under the Industrial Relations (General) Regulation 2001 made pursuant to the Industrial Relations Act 1996, the Industrial Registrar may waive payment of, or reduce, the fee for services, where the Registrar is satisfied that the applicant will “suffer financial hardship if required to pay the fee”.

The Industrial Registrar, Deputy Industrial Registrar or Assistant Deputy Industrial Registrar will consider an application to waive or reduce the fee as a matter of priority. Where possible you will be advised verbally of the decision. Where the application for waiver or reduction is unsuccessful, you will be required to pay the lodgement fee immediately.

Please note that an application can only be accepted where the lodgement fee (including any reduced fee determined by the Registrar) is paid, or such fee has been waived.

APPLICANT DETAILS

Address:

Postcode

Date of birth: ……/……/…… Driver's Licence No: Expires: ……/……/…….

Telephone Number(s):

Date termination took effect: ………/………/………. I ask that the fee payable on my application to the Industrial Relations Commission of New South Wales be waived or reduced to $ …… . I ask this because payment of the fee would cause me to suffer financial hardship. I declare that to the best of my knowledge and belief the information set out in this application is true and that, where an estimate is given, it is given in good faith. It is a true statement of my assets, income and liabilities. I have no other assets or income or any interest in superannuation funds or estates, other than set out in this application.

Date: ………/………./……… Applicant’s Signature:

WARNING There are severe penalties for making false or misleading statements on this form to try to get fees waived or reduced. Section 178BB of the Crimes Act 1900 provides: Whosoever, with intent to obtain … any financial advantage of any kind whatsoever, makes… any statement (whether or not in writing) which he or she knows to be false or misleading in a material particular or which is false or misleading in a material particular and is made with reckless disregard as to whether it is true or is false or misleading in a material particular shall be liable to imprisonment for 5 years.

of 6 1. INCOME FROM EMPLOYMENT A. Lump Sum Please provide details below of any moneys you received as final payment from the employer against whom you are claiming relief from unfair dismissal: Salary (net) $…………… Severance Payment $…………… Payment in lieu of Recreation leave/Long Service Leave $……………

B. Other Payments Do you receive income from any other employment (ie, employment other than that for which you are claiming relief from unfair dismissal) or fees for contractual arrangements? Please include employment that is full-time, part-time, permanent, temporary, casual, etc. If more than one, attach a list. YES  (If YES, please complete the section below) NO  (If NO, please go to 2. OTHER INCOME)

I am employed by My employer’s address is My income after tax is $…………….. per fortnight

2. OTHER INCOME Do you receive income in addition to that shown above? YES  (If YES, please complete the section below) NO  (If NO, please go to 3. SUMMARY OF INCOME) The details of other income I receive including any maintenance payments for myself or my children, Family Allowance, rent or board from people living in the same premises as I do, or premises I own, are as follows: NATURE OF INCOME Social Security $…………… per fortnight If you are receiving Social Security, write your Social Security number here: Family Allowance $…………… per fortnight Other Income: $…………… per fortnight $…………… per fortnight $…………… per fortnight

TOTAL OTHER INCOME $…………… per fortnight

of 6 3. SUMMARY OF INCOME The total amount of income I receive per fortnight is as follows:

INCOME FROM EMPLOYMENT (from 1 above) $…………… Lump Sum

$…………… per fortnight

OTHER INCOME (from 2 above) $…………… per fortnight

4. DEPENDENTS I have (state number) ……….. dependants. Their relationship to me, and in the case of children, their ages, are: Relationship

Relationship

Relationship Relationship Details of separate income received by my dependants are as follows (please show amount(s) received after tax): Full name $………………………… per fortnight $………………………… per fortnight $………………………… per fortnight $………………………… per fortnight

5. SAVINGS Do you have any savings?

YES  (If YES, please complete the section below) NO  (If NO, please go to 6. OTHER ASSETS) The details of bank accounts, credit union accounts, building society accounts, investment accounts, etc., are as follows (please indicate joint accounts by placing [J] next to the account number):

TYPE OF NAME OF INSTITUTION ACCOUNT JOINT CURRENT ACCOUNT(S) NUMBER BALANCE $ $ $ $ $ $ NB: Interest received from these accounts should be included at 2. OTHER INCOME

of 6 6. OTHER ASSETS Do you have any assets other than the ones already listed on this application. Assets can include a block of land, houses, cars, boats, shares, etc. YES  (If YES, please complete the section below) NO  (If NO, please go to 7. LIABILITIES) The assets I have are as follow (If ownership of any of your assets is shared with another person(s), indicate what portion share you have, eg, half share in …): DESCRIPTION OF ASSETS ESTIMATED NET VALUE OF ASSET* $ Real Estate (House and Land) Other Real Estate give addresses of all houses and land

Motor Vehicle Model Registration Number 2nd Motor Vehicle Model Registration Number Household Furniture Electrical Goods Shares or Investments Boat Caravan Other Assets (specify)

*The “estimated net value” is what you would expect to receive for the asset or your share of it after any secured liabilities, eg, mortgages, hire purchases have been paid off if it was sold in the current market. NB: Income received from these assets (eg, rent, dividends) should be included at 2. OTHER INCOME.

7. LIABILITIES I have the following liabilities: LIABILITIES OWED TO BALANCE Mortgage $ Car Loan $ Personal Loan $ Credit Card $ 2nd Credit Card $ 3rd Credit Card $ HECS Debt $ Other Liabilities (specify)

of 6 8. EXPENSES I am committed to the following fortnightly expenses: Rent/Board $………………………… per fortnight Mortgage Repayments $………………………… per fortnight Living Expenses (food, clothing, etc) $………………………… per fortnight Gas, Electricity $………………………… per fortnight Telephone $………………………… per fortnight Health Fund Contributions $………………………… per fortnight Rates (Council, Water, etc) $………………………… per fortnight Loan/Credit Card repayments $………………………… per fortnight Superannuation Fund $………………………… per fortnight Car Expenses $………………………… per fortnight Fares/Petrol, etc) $………………………… per fortnight Maintenance $………………………… per fortnight Insurance $………………………… per fortnight Superannuation $………………………… per fortnight School Expenses $………………………… per fortnight Other (specify): $………………………… per fortnight $………………………… per fortnight $………………………… per fortnight

TOTAL $………………………… per fortnight

9. OTHER COMMENTS Please include any other information/comments about you or your dependant’s circumstances which you believe should be taken into account in deciding your request. State why payment of the fee would cause you hardship.

of 6 For Registry Use Only

APPLICATION  APPROVED  NOT APPROVED IF APPROVED: FEE  WAIVED IN FULL  REDUCED TO $…………

This application has/has not been approved pursuant to Clause 23F of the Industrial Relations (General) Regulation 2001.

…………………………………………………….

ASSISTANT/DEPUTY/INDUSTRIAL REGISTRAR …../…../…..

Applicant advised of decision verbally/in writing

…………………………………………………… Signature of Action Officer …./…./….